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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426747
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:40:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2021 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210205124311
FACILITY NAME:ANGELIC HANDS ASSISTED LIVINGFACILITY NUMBER:
336426747
ADMINISTRATOR:LUNA, SYNTHIA MARIEFACILITY TYPE:
740
ADDRESS:82397 STRADIVARI ROADTELEPHONE:
(760) 342-0248
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 1DATE:
06/27/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tinisha Sherley, caregiverTIME COMPLETED:
10:48 AM
ALLEGATION(S):
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Staff did not notify resident's POA of change in resident's condition.
Staff did not meet resident’s medical care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with caregiver Tinisha Sherley and explained the purpose of the visit. This report was also discussed with the Licensee over the phone. Department staff investigated these allegations.

Allegation #1 “Staff did not notify resident's POA of the change in resident's condition". The allegation alleged that the facility refuses to provide the Power of Attorney (POA) with any reports or information regarding resident #1's (R1's) level of health and well-being. Department staff interview with the reporting party (RP) provided no additional details about this allegation. Department staff interview with the Licensee revealed that the Licensee denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2 “Staff did not meet resident’s medical care needs”. The allegation alleged that the facility’s staff does not monitor R1’s medication condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210205124311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747
VISIT DATE: 06/27/2023
NARRATIVE
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The allegation alleged that in November 2020, R1’s physician ordered that the facility transport R1 to the hospital. However, the facility did not allow it. Department staff interview with the reporting party (RP) provided no additional details about this allegation. Department staff interview with the Licensee revealed that whenever R1 requires medication attention, R1 receives it. Department staff interview with R1 revealed that R1 does not want to leave the facility and likes the care provided. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2